Quantitative assessment of prosthesis press-fit fixation

ABSTRACT

A system and method for quantitatively assessing a press fit value (and provide a mechanism to evaluate optimal quantitative values) of any implant/bone interface regardless the variables involved including bone site preparation, material properties of bone and implant, implant geometry and coefficient of friction of the implant-bone interface without requiring a visual positional assessment of a depth of insertion. The following description is presented to enable one of ordinary skill in the art to make and use the invention and is provided in the context of a patent application and its requirements.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Application62/651,077 filed on Mar. 31, 2018. This application is aContinuation-in-part of application Ser. No. 15/716,533 filed on Sep.27, 2017 and a Continuation-in-part of application Ser. No. 15/284,091filed on Oct. 3, 2016. Application Ser. No. 15/716,533 is aContinuation-in-part of application Ser. No. 15/687,324 filed on Aug.25, 2017. Application Ser. No. 15/687,324 is a Continuation ofapplication Ser. No. 15/284,091 filed on Oct. 3, 2016. Application Ser.No. 15/284,091 is a Continuation-in-part of application Ser. No.15/234,782 filed on Aug. 11, 2016. Application Ser. No. 15/234,782 is aContinuation-in-part of application Ser. No. 15/202,434 filed on Jul. 5,2016. Application Ser. No. 15/202,434 claims the benefit of U.S.Provisional Application 62/277,294 filed on Jan. 11, 2016. ApplicationSer. No. 15/234,782 claims the benefit of U.S. Provisional Application62/355,657 filed on Jun. 28, 2016. Application Ser. No. 15/234,782claims the benefit of U.S. Provisional Application 62/353,024 filed onJun. 21, 2016. Application Ser. No. 15/716,533 is a Continuation-in-partof application Ser. No. 15/284,091 filed on Oct. 3, 2016. ApplicationSer. No. 15/716,533 is a Continuation-in-part of application Ser. No.15/234,782 filed on Aug. 11, 2016. Application Ser. No. 15/716,533 is aContinuation-in-part of application Ser. No. 15/202,434 filed on Jul. 5,2016. All of the these identified applications, including parentapplications, are hereby expressly incorporated by reference thereto intheir entireties for all purposes.

FIELD OF THE INVENTION

The present invention relates generally to assessing a quality of apress-fit installation of a structure, and more specifically, but notexclusively, to quantitative assessment of prosthesis press-fit fixationinto a bone cavity, for example, assessment of press-fit fixation of anacetabular cup into a prepared (e.g., relatively under-reamedacetabulum) bone cavity.

BACKGROUND OF THE INVENTION

The subject matter discussed in the background section should not beassumed to be prior art merely as a result of its mention in thebackground section. Similarly, a problem mentioned in the backgroundsection or associated with the subject matter of the background sectionshould not be assumed to have been previously recognized in the priorart. The subject matter in the background section merely representsdifferent approaches, which in and of themselves may also be inventions.

Initial stability of metal backed acetabular components is an importantfactor in an ultimate success of cement-less hip replacement surgery.The press fit technique, which involves impaction of an oversized(relative to a prepared cavity in an acetabulum) porous coatedacetabular cup into an undersized cavity (relative to the prosthesis tobe installed) of bone produces primary stability through cavitydeformation and frictional forces, and has shown excellent long termresults. This press fit technique avoids use of screw fixationassociated with risk of neurovascular injury, fretting and metallosis,and egress of particulate debris and osteolysis.

However, it has been difficult to assess a primary implant stability dueto complex nature of bone-implant interface, or to evaluate an optimalpress fit fixation. The initial interaction of the implant with bone isdue the circumferential surface interference at the aperturetransitioning to compression of the cavity with deeper insertion. Acompromise exists between seating the cup enough to get sufficientprimary stability and avoiding fracture of bone. There is noquantitative method in current clinical practice to assess the primarystability of the implant, with surgeons relying solely on theirqualitative proprioceptive senses (tactile, auditory, and visual) todetermine point of optimal press fit fixation.

Four factors associated with difficulty obtaining optimal press fitfixation: i) no current method exists to gauge the resulting stressfield in bone during the impaction of an oversized implant; ii) thematerial properties of bone (bone density) vary significantly based onage and sex of the patient, and are unknown to the surgeon; iii) currentmallet based techniques for impaction do not allow surgeons to control(quantify and increment) the magnitude of force using in installation;and iv) surgeons are charged with the difficult task of: a) applying andmodulating magnitude of force; b) deciding when to stop application offorce; and c) assessing a quality of press fit fixation allsimultaneously in their “mind's eye” during the process of impaction.

A significance of this problem on patients, medical practice and economyis great. Although Total Hip Replacement (THR) is widely recognized as asuccessful operation, 3 to 25% of operations fail requiring revisionsurgery. Aseptic loosening of press fit THR components is one of themost common causes of failure at 50% to 90% and closely associated withinsufficient initial fixation. Inadequate stabilization may lead to latepresentation of aseptic loosening due to formation of fibrous tissue andover stuffing the prosthesis may lead to occult and/or frankperi-prosthetic fractures. The cost of poor initial press fit fixationresulting from (loosening, occult fractures, subsidence, fretting,metallosis, and infections) maybe under reported however estimated to bein tens of billions of dollars. Over 400,000 total hip replacements aredone in US every year, over 80% of which are done by surgeons who doless than ten per year. The limitations of this procedure producefrustration and anxiety for surgeons, physical and emotional pain forpatients, at great costs to society.

Initial implant fixation can be measured by pullout, lever out, andtorsional test in vitro; however, these methods have minimal utility ina clinical setting in that they are destructive. Vibration analysis,where secure and loose implants can be distinguished by the differingfrequency responses of the implant bone interface, has been successfullyemployed in evaluating fixation of dental implants however, thistechnology has not been easily transferable to THR surgery, andcurrently has no clinical utility.

In clinical practice, surgeons err on the side of not overstuffing theprosthesis which leads to a smaller under ream (or line to line ream)and screw fixation with attendant risks.

Finally, several visual tracking methods (Computer Navigation,Fluoroscopy, MAKO Robotics) are utilized to assess the depth of cupinsertion during impaction in order to guide application of force;however, these techniques, from and engineering perspective, areconsidered to be open loop, where the feedback response to the surgeonis not a force (sensory) response, and therefore does not provide anyinformation about the stress response of the cavity.

A system and method is needed to quantitatively assess a press fit value(and provide a mechanism to evaluate optimal quantitative values) of anyimplant/bone interface regardless the variables involved including bonesite preparation, material properties of bone and implant, implantgeometry and coefficient of friction of the implant-bone interfacewithout requiring a visual positional assessment of a depth ofinsertion.

BRIEF SUMMARY OF THE INVENTION

Disclosed is a system and method for quantitatively assessing a pressfit value (and provide a mechanism to evaluate optimal quantitativevalues) of any implant/bone interface regardless the variables involvedincluding bone site preparation, material properties of bone andimplant, implant geometry and coefficient of friction of theimplant-bone interface without requiring a visual positional assessmentof a depth of insertion.

The following summary of the invention is provided to facilitate anunderstanding of some of the technical features related to installationof an acetabular cup prosthesis into a relatively undersized preparedcavity in an acetabulum, and is not intended to be a full description ofthe present invention. A full appreciation of the various aspects of theinvention can be gained by taking the entire specification, claims,drawings, and abstract as a whole. The present invention is applicableto other press fit fixation systems, including installation of differentprostheses into different locations, and installation of otherstructures into an elastic substrate.

Some embodiments of the proposed technology may enable a standardizationof: a) application of force; and b) assessment of quality of fixation injoint replacement surgery, such that surgeons of all walks of life,whether they perform five or 500 hip replacements per year, will produceconsistently superior/optimum/perfect results with respect to press fitfixation of implants in bone.

From the surgeon perspective this standardization process will level theplaying field between the more and less experienced surgeons, leading toless stress and anxiety for the surgeons affecting their mentalwellness. From the patient perspective there will be a decrease in thenumber of complications and ER admissions leading to decrease inmorbidity and mortality. From an economic perspective there will be asignificant cost savings for the government and insurance companies dueto a decrease in the number of readmissions and revision surgery's,particularly since revision surgery in orthopedics accounts for up to30% of a 50-billion-dollar industry.

To address this deficiency, some embodiments and related applicationshave considered a novel means of accessing and processing various forceresponses of bone (Invasive Sensing Mechanism) and propose that thismechanism can guide application of force to the bone cavity, to obtainoptimal press fit technologically without reliance on surgeon'sproprioception. There are several possible outcomes of this proposal, ifvalidated, including that it may make joint replacement surgery asignificantly safer operation leading to less morbidity andcomplications, readmissions, and revision surgery; resulting in greatbenefits to patients, surgeons and society in general.

An embodiment of the present invention may include a series ofoperations for installing a prosthesis into a relatively undersizedcavity prepared in a portion of bone, including communicating, using aninstallation agency, a quantized applied force to a prosthesis beingpress-fit into the cavity; monitoring a rigidity metric and anelasticity metric of the prosthesis with respect to the cavity (someembodiments do this in real-time or near real-time without requiringimaging or position-determination technology); further processingresponsive to the rigidity and elasticity metrics, including continuingto install the prosthesis at present level of applied force whilemonitoring the metrics when the metrics indicate that installationchange is acceptable and a risk of fracture remains at an acceptablelevel, increasing the applied force and continuing applying theinstallation agency while monitoring the metrics when the metricsindicate that installation change is minimal and a risk of fractureremains at an acceptable level, or suspending operation of theinstallation agency when the metrics indicate that installation changeis minimal when a risk of fracture increases to an unacceptable level.Some embodiments may determine rigidity/elasticity from position, orvibration spectrum in air (sound) or bone. In some embodiments, whilerigidity and elasticity may be determined in several different ways,some of which are disclosed herein, some implementations may determine aquantitative assessment responsive to evaluations of both responsiverigidity and elasticity factors during controlled operation of aninsertion agency communicating an application force to a prosthesis(best fixation short of fracture—BFSF). BFSF may be related to one orboth of these rigidity and elasticity factors.

An apparatus for insertion of a prosthesis into a cavity formed in aportion of bone, the prosthesis relatively oversized with respect to thecavity, including an insertion device providing an insertion agency tothe prosthesis, the insertion agency operating over a period, the periodincluding an initial prosthesis insertion act with the insertion deviceand a subsequent prosthesis insertion act with the insertion device; anda system physically coupled to the insertion device configured toprovide a parametric evaluation of an extractive force of an interfacebetween the prosthesis and the cavity during the period, the parametricevaluation including an evaluation of a set of factors of the prosthesiswith respect to the cavity, the set of factors including one or more ofa rigidity factor, an elasticity factor, and a combination of therigidity factor and the elasticity factor.

A method for an insertion of an implant into a cavity in a portion ofbone, the cavity relatively undersized with respect to the implant,including a) providing, using a device, an implant insertion agency tothe implant to transition the implant toward a deepen insertion into thecavity; and b) predicting, responsive to the implant insertion agency, apress-fit fixation of the implant at an interface between the implantand the cavity during the providing of the implant insertion agency.

An impact control method for installing an implant into a cavity in aportion of bone, the cavity relatively undersized with respect to theimplant, including a) imparting a first initial known force to theimplant; b) imparting a first subsequent known force to the implant, thefirst subsequent known force about equal to the first initial force; c)measuring, for each the imparted known force, an Xth number measuredimpact force; d) comparing the Xth measured impact force to the Xth−1measured impact force against a predetermined threshold for a thresholdtest; and e) repeating steps b)-d) as long as the threshold test isnegative.

A method for an automated installation of an implant into a cavity in aportion of bone, including a) initiating an application of aninstallation agency to the implant, the installation agency including anenergy communicated to the implant moving the implant deeper into thecavity in response thereto; b) recording a set of measured responseforces responsive to the installation agency; c) continuing applying andrecording until a difference in successive measured responses is withina predetermined threshold to estimate no significant displacement of theimplant at the energy as the implant is installed into the cavity; d)increasing the energy; e) repeating steps b)-c) until a plateau of theset of the measured response forces; and f) terminating steps b)-e) whena steady-state is detected.

A method for insertion of a prosthesis into a cavity formed in a portionof bone, the prosthesis relatively oversized with respect to the cavity,including a) applying an insertion agency to the prosthesis, theinsertion agency operating over a period, the period including aninitial prosthesis insertion act with the insertion device and asubsequent prosthesis insertion act with the insertion device; and b)providing a parametric evaluation of an extractive force of an interfacebetween the prosthesis and the cavity during the period, the parametricevaluation including an evaluation of a set of factors of the prosthesiswith respect to the cavity, the set of factors including one or more ofa rigidity factor, an elasticity factor, and a combination of therigidity factor and the elasticity factor.

An apparatus for installing a prosthesis into a relatively undersizedprepared cavity in a portion of a bone, including a force applicatoroperating an insertion agency for installing the prosthesis into thecavity; a force transfer structure, coupled to the force applicator andto the prosthesis, for conveying an application force F1 to theprosthesis, the application force F1 derived from the insertion agency;a force sensing system determining a force response of the prosthesis atan interface of the prosthesis and the cavity, the force responseresponsive to the application force F1; and a controller, coupled toforce applicator and to the force sensing system, the controller settingan operational parameter for the insertion agency, the operationalparameter establishing the application force F1, the controllerresponsive to the force response to establish a set of parametersincluding one or more of a rigidity metric, an elasticity metric, andcombinations thereof.

A method for installing a prosthesis into a relatively undersized cavityprepared in a portion of bone, including a) communicating an applicationforce F1 to the prosthesis; b) monitoring a rigidity factor and anelasticity factor of the prosthesis within the cavity during applicationof the application force F1; c) repeating a)-b) until the rigidityfactor meets a first predetermined goal; d) increasing, when therigidity factor meets the predetermined goal, the application force F1;e) repeating a)-d) until the elasticity factor meets a secondpredetermined goal; and f) suspending a) when the elasticity factormeets the first goal and the rigidity factor meets the second goal.

An acetabular cup for a prepared cavity in a portion of bone, includinga generally hemispherical exterior shell portion defining a generallyhemispherical interior cavity; and a snubbed polar apex portion of thegenerally hemispherical exterior shell portion without degradation ofthe generally hemispherical interior cavity producing a polar gap withinthe prepared cavity when fully seated.

An implant for a prepared cavity in a portion of bone, including anexterior shell portion having an interior cavity; and a snubbed polarapex portion of the exterior shell portion without degradation of theinterior cavity producing a polar gap within the prepared cavity whenfully seated.

An apparatus for insertion of a prosthesis into a cavity formed in aportion of bone, the prosthesis relatively oversized with respect to thecavity, including means for applying an insertion agency to theprosthesis, the insertion agency operating over a period, the periodincluding an initial prosthesis insertion act with the insertion deviceand a subsequent prosthesis insertion act with the insertion device; andmeans, physically coupled to the insertion device, for determining aparametric evaluation of an extractive force of an interface between theprosthesis and the cavity during the period, the parametric evaluationincluding an evaluation of a set of factors of the prosthesis withrespect to the cavity, the set of factors including one or more of arigidity factor, an elasticity factor, and a combination of the rigidityfactor and the elasticity factor.

Any of the embodiments described herein may be used alone or togetherwith one another in any combination. Inventions encompassed within thisspecification may also include embodiments that are only partiallymentioned or alluded to or are not mentioned or alluded to at all inthis brief summary or in the abstract. Although various embodiments ofthe invention may have been motivated by various deficiencies with theprior art, which may be discussed or alluded to in one or more places inthe specification, the embodiments of the invention do not necessarilyaddress any of these deficiencies. In other words, different embodimentsof the invention may address different deficiencies that may bediscussed in the specification. Some embodiments may only partiallyaddress some deficiencies or just one deficiency that may be discussedin the specification, and some embodiments may not address any of thesedeficiencies.

Other features, benefits, and advantages of the present invention willbe apparent upon a review of the present disclosure, including thespecification, drawings, and claims.

BRIEF DESCRIPTION OF THE DRAWINGS

The accompanying figures, in which like reference numerals refer toidentical or functionally-similar elements throughout the separate viewsand which are incorporated in and form a part of the specification,further illustrate the present invention and, together with the detaileddescription of the invention, serve to explain the principles of thepresent invention.

FIG. 1 illustrates an smart tool for prosthesis installation;

FIG. 2 illustrates an identification of forces in a press fit fixationinstallation of a prosthesis;

FIG. 3 illustrates a set of relationships between measured impact force(e.g., F5), number of impacts (NOI), cup insertion (CI), and impactenergy Joules (J);

FIG. 4 illustrates a relationship of force in bone (e.g., F5) and cupinsertion (CI) for 1.0 Joules (J);

FIG. 5 illustrates a relationship of force in bone (e.g., F5) and cupinsertion (CI) for 1.8 Joules (J);

FIG. 6 illustrates a relationship between a rate of insertion (1/NOI),extractive force (e.g., F4), and impact energy;

FIG. 7 illustrates a relationship between maximum applied force (e.g.,F1) and cup insertion (CI);

FIG. 8 illustrates a relationship between maximum applied force (e.g.,F1) and an extractive force (e.g., F4);

FIG. 9 illustrates a representative force response for incrementingimpact energies;

FIG. 10 illustrates a comparison of a quantitative system versus aqualimetric system for evaluating a real time non-visually tracked pressfit fixation;

FIG. 11-FIG. 14 illustrate a set of rigidity metric measurements;

FIG. 11 illustrates a comparison of F5 to F1;

FIG. 12 illustrates a comparison of ΔF5 to a predetermined threshold(e.g., 0.0);

FIG. 13 illustrates a comparison of F2 to F1;

FIG. 14 illustrates a comparison of ΔF2 to a predetermined threshold(e.g., 0.0);

FIG. 15 illustrates an evolution of an acetabular cup consistent withimproving press fit fixation; and

FIG. 16 illustrates a particular embodiment of a BMD_(X) force sensingtool.

DETAILED DESCRIPTION OF THE INVENTION

Embodiments of the present invention provide a system and method forquantitatively assessing a press fit value (and provide a mechanism toevaluate optimal quantitative values) of any implant/bone interfaceregardless the variables involved including bone site preparation,material properties of bone and implant, implant geometry andcoefficient of friction of the implant-bone interface without requiringa visual positional assessment of a depth of insertion. The followingdescription is presented to enable one of ordinary skill in the art tomake and use the invention and is provided in the context of a patentapplication and its requirements.

Various modifications to the preferred embodiment and the genericprinciples and features described herein will be readily apparent tothose skilled in the art. Thus, the present invention is not intended tobe limited to the embodiment shown but is to be accorded the widestscope consistent with the principles and features described herein.

Definitions

Unless otherwise defined, all terms (including technical and scientificterms) used herein have the same meaning as commonly understood by oneof ordinary skill in the art to which this general inventive conceptbelongs. It will be further understood that terms, such as those definedin commonly used dictionaries, should be interpreted as having a meaningthat is consistent with their meaning in the context of the relevant artand the present disclosure, and will not be interpreted in an idealizedor overly formal sense unless expressly so defined herein.

The following definitions apply to some of the aspects described withrespect to some embodiments of the invention. These definitions maylikewise be expanded upon herein.

As used herein, the term “or” includes “and/or” and the term “and/or”includes any and all combinations of one or more of the associatedlisted items. Expressions such as “at least one of,” when preceding alist of elements, modify the entire list of elements and do not modifythe individual elements of the list.

As used herein, the singular terms “a,” “an,” and “the” include pluralreferents unless the context clearly dictates otherwise. Thus, forexample, reference to an object can include multiple objects unless thecontext clearly dictates otherwise.

Also, as used in the description herein and throughout the claims thatfollow, the meaning of “in” includes “in” and “on” unless the contextclearly dictates otherwise. It will be understood that when an elementis referred to as being “on” another element, it can be directly on theother element or intervening elements may be present therebetween. Incontrast, when an element is referred to as being “directly on” anotherelement, there are no intervening elements present.

As used herein, the term “set” refers to a collection of one or moreobjects. Thus, for example, a set of objects can include a single objector multiple objects. Objects of a set also can be referred to as membersof the set. Objects of a set can be the same or different. In someinstances, objects of a set can share one or more common properties.

As used herein, the term “adjacent” refers to being near or adjoining.Adjacent objects can be spaced apart from one another or can be inactual or direct contact with one another. In some instances, adjacentobjects can be coupled to one another or can be formed integrally withone another.

As used herein, the terms “connect,” “connected,” and “connecting” referto a direct attachment or link. Connected objects have no or nosubstantial intermediary object or set of objects, as the contextindicates.

As used herein, the terms “couple,” “coupled,” and “coupling” refer toan operational connection or linking. Coupled objects can be directlyconnected to one another or can be indirectly connected to one another,such as via an intermediary set of objects.

The use of the term “about” applies to all numeric values, whether ornot explicitly indicated. This term generally refers to a range ofnumbers that one of ordinary skill in the art would consider as areasonable amount of deviation to the recited numeric values (i.e.,having the equivalent function or result). For example, this term can beconstrued as including a deviation of ±10 percent of the given numericvalue provided such a deviation does not alter the end function orresult of the value. Therefore, a value of about 1% can be construed tobe a range from 0.9% to 1.1%.

As used herein, the terms “substantially” and “substantial” refer to aconsiderable degree or extent. When used in conjunction with an event orcircumstance, the terms can refer to instances in which the event orcircumstance occurs precisely as well as instances in which the event orcircumstance occurs to a close approximation, such as accounting fortypical tolerance levels or variability of the embodiments describedherein.

As used herein, the terms “optional” and “optionally” mean that thesubsequently described event or circumstance may or may not occur andthat the description includes instances where the event or circumstanceoccurs and instances in which it does not.

As used herein, the term “bone” means rigid connective tissue thatconstitute part of a vertebral skeleton, including mineralized osseoustissue, particularly in the context of a living patient undergoing aprosthesis implant into a portion of cortical bone. A living patient,and a surgeon for the patient, both have significant interests inreducing attendant risks of conventional implanting techniques includingfracturing/shattering the bone and improper installation and positioningof the prosthesis within the framework of the patient's skeletal systemand operation.

As used herein, the term “size” refers to a characteristic dimension ofan object. Thus, for example, a size of an object that is spherical canrefer to a diameter of the object. In the case of an object that isnon-spherical, a size of the non-spherical object can refer to adiameter of a corresponding spherical object, where the correspondingspherical object exhibits or has a particular set of derivable ormeasurable properties that are substantially the same as those of thenon-spherical object. Thus, for example, a size of a non-sphericalobject can refer to a diameter of a corresponding spherical object thatexhibits light scattering or other properties that are substantially thesame as those of the non-spherical object. Alternatively, or inconjunction, a size of a non-spherical object can refer to an average ofvarious orthogonal dimensions of the object. Thus, for example, a sizeof an object that is a spheroidal can refer to an average of a majoraxis and a minor axis of the object. When referring to a set of objectsas having a particular size, it is contemplated that the objects canhave a distribution of sizes around the particular size. Thus, as usedherein, a size of a set of objects can refer to a typical size of adistribution of sizes, such as an average size, a median size, or a peaksize.

As used herein, mallet or hammer refers to an orthopedic device made ofstainless steel or other dense material having a weight generally acarpenter's hammer and a stonemason's lump hammer.

As used herein, an impact force for impacting an acetabular component(e.g., an acetabular cup prosthesis) includes forces from striking animpact rod multiple times with the orthopedic device that are generallysimilar to the forces that may be used to drive a three inch nail into apiece of lumber using the carpenter's hammer by striking the nailapproximately a half-dozen times to completely seat the nail. Withoutlimiting the preceding definition, a representative value in someinstances includes a force of approximately 10 lbs./square inch.

As used herein, the term “realtime” sensing means sensing relevantparameters (e.g., force, acceleration, vibration, acoustic, and thelike) during processing (e.g., installation, reaming, cutting) withoutstopping or suspending processing for visual evaluation of insertiondepth of a prosthesis into a prepared cavity.

The following description relates to improvements in a wide-range ofprostheses installations into live bones of patients of surgeons. Thefollowing discussion focuses primarily on total hip replacement (THR) inwhich an acetabular cup prosthesis is installed into the pelvis of thepatient. This cup is complementary to a ball and stem (i.e., a femoralprosthesis) installed into an end of a femur engaging the acetabulumundergoing repair.

Embodiments of the present invention may include one of more solutionsto the above problems. U.S. Pat. No. 9,168,154, expressly incorporatedby reference thereto in its entirety for all purposes, includes adescription of several embodiments, sometimes referred to herein as aBMD3 device, some of which illustrate a principle for breaking downlarge forces associated with the discrete blows of a mallet into aseries of small taps, which in turn perform similarly in a stepwisefashion while being more efficient and safer. The BMD3 device producesthe same displacement of the implant without the need for the largeforces from the repeated impacts from the mallet. The BMD3 device mayallow modulation of force required for cup insertion based on bonedensity, cup geometry, and surface roughness. Further, a use of the BMD3device may result in the acetabulum experiencing less stress anddeformation and the implant may experience a significantly smoothersinking pattern into the acetabulum during installation. Someembodiments of the BMD3 device may provide a superior approach to theseproblems, however, described herein are two problems that can beapproached separately and with more basic methods as an alternative to,or in addition to, a BMD3 device. An issue of undesirable torques andmoment arms is primarily related to the primitive method currently usedby surgeons, which involves manually banging the mallet on the impactionplate. The amount of force utilized in this process is alsonon-standardized and somewhat out of control.

With respect to the impaction plate and undesirable torques, anembodiment of the present invention may include a simple mechanicalsolution as an alternative to some BMD3 devices, which can be utilizedby the surgeon's hand or by a robotic machine. A direction of the impactmay be directed or focused by any number of standard techniques (e.g.,A-frame, C-arm or navigation system). Elsewhere described herein is arefinement of this process by considering directionality in the reamingprocess, in contrast to only considering it just prior to impaction.First, we propose to eliminate the undesirable torques by delivering theimpacts by a sledgehammer device or a (hollow cylindrical mass) thattravels over a stainless rod.

As noted in the background, the surgeon prepares the surface of thehipbone which includes attachment of the acetabular prosthesis to thepelvis. Conventionally, this attachment includes a manual implantationin which a mallet is used to strike a tamp that contacts some part ofthe acetabular prosthesis. Repeatedly striking the tamp drives theacetabular prosthesis into the acetabulum. Irrespective of whethercurrent tools of computer navigation, fluoroscopy, robotics (and otherintra-operative measuring tools) have been used, it is extremelyunlikely that the acetabular prosthesis will be in the correctorientation once it has been seated to the proper depth by the series ofhammer strikes. After manual implantation in this way, the surgeon thenmay apply a series of adjusting strikes around a perimeter of theacetabular prosthesis to attempt to adjust to the desired orientation.Currently such post-impaction result is accepted as many surgeonsbelieve that post-impaction adjustment creates an unpredictable andunreliable change which does not therefore warrant any attempts forpost-impaction adjustment.

In most cases, any and all surgeons including an inexperienced surgeonmay not be able to achieve the desired orientation of the acetabularprosthesis in the pelvis by conventional solutions due tounpredictability of the orientation changes responsive to theseadjusting strikes. As noted above, it is most common for any surgeon toavoid post-impaction adjustment as most surgeons understand that they donot have a reliable system or method for improving any particularorientation and could easily introduce more/greater error. The computernavigation systems, fluoroscopy, and other measuring tools are able toprovide the surgeon with information about the current orientation ofthe prosthesis during an operation and after the prosthesis has beeninstalled and its deviation from the desired orientation, but thenavigation systems (and others) do not protect against torsional forcescreated by the implanting/positioning strikes. The prosthesis will findits own position in the acetabulum based on the axial and torsionalforces created by the blows of the mallet. Even those navigation systemsused with robotic systems (e.g., MAKO) that attempt to secure an implantin the desired orientation prior to impaction are not guaranteed toresult in the installation of the implant at the desired orientationbecause the actual implanting forces are applied by a surgeon swinging amallet to manually strike the tamp.

A Behzadi Medical Device (BMD) is herein described and enabled thateliminates this crude method (i.e., mallet, tamp, and surgeon-appliedmechanical implanting force) of the prosthesis (e.g., the acetabularcup). A surgeon using the BMD is able to insert the prosthesis exactlywhere desired with proper force, finesse, and accuracy. Depending uponimplementation details, the installation includes insertion of theprosthesis into patient bone, within a desired threshold of metrics forinsertion depth and location) and may also include, when appropriateand/or desired, positioning at a desired orientation with the desiredthreshold further including metrics for insertion orientation). The useof the BMD reduces risks of fracturing and/or shattering the bonereceiving the prosthesis and allows for rapid, efficient, and accurate(atraumatic) installation of the prosthesis. The BMD provides a viableinterface for computer navigation assistance (also useable with allintraoperative measuring tools including fluoroscopy) during theinstallation as a lighter more responsive touch may be used.

The BMD encompasses many different embodiments for installation and/orpositioning of a prosthesis and may be adapted for a wide range ofprostheses in addition to installation and/or positioning of anacetabular prosthesis during THR, including examples of a device, whichmay be automated, for production and/or communication of an installationagency to a prosthesis.

FIG. 1 illustrates a smart tool 100 for prosthesis installation,including structures and methods for operation of a force agency 105 anda responsive quantitative assessment 110 with respect to installation ofa prosthesis P (e.g., an acetabular cup) into a prepared cavity in aportion of bone (e.g., an acetabulum). Agency 105 may include severaldifferent types of force applicators, including vibratory insertionagencies and/or controlled impaction agencies and/or constant appliedforce and/or other force profile as described in the incorporatedpatents and applications. Quantitative assessment 110 may include aprocessor and sensors for evaluating parameters and functions asdescribed herein including a rigidity metric and an elasticity metric,for press-fit fixation of prosthesis P, such as in realtime ornear-realtime operation of force agency 105.

FIG. 2 illustrates an identification of forces in a press fit fixationinstallation of a prosthesis. These forces, as illustrated, include F1(applied force), F2 (responsive force in smart tool), F3 (resistiveforce to installation), F4 (axial extractive force), and/or F5 (force inbone substrate). There may be other forces that may be measured ordetermined to be correlated, responsive, and/or related to these forces.In some circumstances, multiple related or correlated forces may be“fused” into a fusion force that provides a robust evaluation of thecomponent forces, with any appropriate individual weightings ofcomponent forces in the fused force. That is some embodiments, apress-fit fixation may be assessed based upon contributions frommultiple forces fused together rather than evaluations of individualforces or derivatives thereof.

When press fitting an acetabular component into an undersized cavity,one may expect to encounter three regions with distinct characteristics:(a) poor seating and poor pull out force; (b) deep insertion and goodpull out force; and (c) full insertion which may also have strongfixation but includes higher (and possibly much higher) risk offracture.

Some embodiments may exhibit relationships between extraction force (F4)and cup insertion CI with respect to similarity and proportionality to astandard stress/strain curve of material deformation.

While two collisions occur during the process of prosthesis impactioninto bone in some embodiments for each force application, a proximalcollision is usually elastic and typically presents a maximum value ofF1 for any given impact energy E of the force application. A distalcollision is conversely initially inelastic and progresses to an elasticstate as insertion no longer occurs. In some experiments, forcemeasurements in the impaction rod (F2) and bone (F5) may represent thedistal collision.

FIG. 3 illustrates a set of relationships between measured impact force(e.g., F2, F3, and/or F5 and/or derivatives and/or combinationsthereof), number of impacts (NOI), cup insertion (CI), and impact energyJoules (J). Experiments in the study of vibratory insertion oforthopedic implants [Published Patent App. Invasive Sensing Mechanism:Pub No. 20170196506, incorporated herein by reference in its entiretyfor all purposes] where an oversized acetabular prosthesis, ZimmerContinum Cup (62 mm) was inserted into an undersized (61 mm) bonesubstitute cavity (20 lbs Urethane foam), using three differentinsertion techniques including controlled impaction, vibratoryinsertion, and constant insertion. The forces at play were considered inFIG. 2. An 8900N force gauge was placed within the polyurethane sampleto measure forces in the cavity F5.

With the controlled impaction technique we tested eight-drop heightsproducing a range of impact energies from 0.2 J to 5.0 J correspondingto impact forces ranging from 550N to 8650N. Five replications wereperformed for each height, with a total sample population of 40 units.For each sample, impacts were repeated at a selected drop height untilimplant displacement between impacts were within the measurement errorof 0.05 mm. Peak impact force in bone F5, total cup insertion CI, andnumber of impacts NOI to full insertion were recorded for each sample.Cup stability was measured by axial extraction force by means of a pulltest using Mark 10 M5-100 test stand and force gauge. The results areshown in Table I.

TABLE I Drop Test Results Maximum Drop Impact Mean Cup Extraction HeightImpact Force in Number of Insertion Force F4 (mm) Energy (J) bone F5 (N)Impacts (mm) (N) 10 0.2 774 52 1.4 71 30 0.6 1641 47 3.5 258 50 1.0 243727 4.7 480 70 1.4 3104 23 6.0 676 90 1.8 3927 16 5.6 765 130 2.5 4870 96.1 827 200 3.9 6814 6 6.2 849 260 5.1 7757 4 6.3 867

These data indicate that every level of impact energy is associated witha final depth of cup insertion CI, a plateauing of the force response inbone F5 to an asymptote, and a certain rate of insertion inverselyrelated to the number of impacts NOI required for insertion. As anexample, it took 4 impacts for a maximum applied force of 7757 N toinsert the cup 6.3 mm, whereas it took 52 impacts for a maximum appliedforce of 774N to insert the cup 1.4 mm.

FIG. 4 illustrates a relationship of force in bone (e.g., F5) and cupinsertion (CI) for 1.0 Joules (J) and FIG. 5 illustrates a relationshipof force in bone (e.g., F5) and cup insertion (CI) for 1.8 Joules (J). Adecaying of the force response in bone F5 to an asymptote (when ΔF5approaches 0) could be used as a parametric value guiding incrementalapplication of energy to obtain optimal press fit fixation of implants.This phenomena is identified herein as the rigidity factor (or rigiditymetric) which appears to reach a maximum for any given impact energy.

FIG. 6 illustrates a relationship between a rate of insertion (1/NOI),extractive force (e.g., F4), and impact energy. A direct relationshipwas observed between rate of insertion, inversely related to number ofimpacts NOI, and the extractive force F4, and this phenomenon is termedan elasticity factor (or elasticity metric), which appears to provide areal-time estimation of the extractive force of the implant/boneinterface, as well as an indirect measure of the elastic/plasticbehavior of the aperture of bone. A decaying rate of insertion isconsidered and appears inversely related to a number of impacts andsuggests an ultimate stress point of the cavity aperture.

FIG. 7 illustrates a relationship between maximum applied force (e.g.,F1) and cup insertion (CI) and FIG. 8 illustrates a relationship betweenmaximum applied force (e.g., F1) and an extractive force (e.g., F4). Therelationships of applied force F1 and cup insertion CI as well asapplied force F1 and extractive force F4 were evaluated and showedcharacteristic non-linear curves.

Of note was the observation that an inflection point or (range) existsabove which increased applied force F1 (impact energies) did not appearto provide any meaningful increase in cup insertion CI or extractionforce F4. As example 1.8 joules of impact energy produced 5.6 mm (89%)of cup insertion CI and 827N (88%) of extraction force F4. An additional3.3 joules of impact energy was required for a marginal insertion gainof 0.7 mm and extraction force gain of 102N.

Questions were posed as to how much force is required for optimal pressfit fixation? Does the insistence to fully seat the cup work against thepatients and surgeon? Do surgeons risk fracturing the acetabulum in thedesire to fully seat the cup? The existence of polar gaps in acetabularpress fit fixation have been clinically studied and shown no adverseoutcomes.

It was contemplated that a point or (a small range), defined by theparametric values above, exists which could produce the best fixationshort of fracture (BFSF) and an embodiment may propose BFSF as an idealendpoint for all press fit joint replacement surgery. BFSF may, in somesituations, act not only as a point of optimal press fit, but alsodefine a sort of speed limit or force limit for the surgeon.

In this application an embodiment may develop a method described as theinvasive sensing mechanism (ISM), by which the end point BFSF can bedefined in four chosen systems. Additionally, an embodiment may developan Automatic Intelligent Prosthesis Installation Device (AI-PID) thatcan quantitatively access this point. The following concept is proposedfor a fixation algorithm to achieve BFSF for any implant/cavityinterface. (A Double Binary Decision)

FIG. 9 illustrates a representative force response for incrementingimpact energies. The rigidity factor represented by plateauing levels offorce in bone (e.g., F5) can be used to guide incremental increase inimpact energy J. For any impact energy J, as the force in bone plateausto a maximum, no further insertion is occurring; a decision can be madeas to whether impact energy should be increased or not. This is thefirst binary decision. The elasticity factor represented by the speed ofinsertion of an implant (e.g., inversely related to number of impacts(NOI) required for insertion) can be used to guide the surgeon as towhether application of force should continue or not. This is the secondbinary decision. Two binary decisions for BFSF which may not includefull seating.

FIG. 10 illustrates a comparison of a quantimetric system (including ameasured quantitative determination/use of BFSF) versus a qualimetricsystem (typically based on a visual qualitative assessment of a depth ofinsertion) for evaluating a real time non-visually tracked press-fitfixation. An invasive sensing mechanism (ISM) and an automaticintelligent prosthesis installation device (AI-PID) may standardize anapplication of force and an assessment of a measured quality of fixationin joint replacement surgery, through exploitation of the relationshipsbetween the force responses in the installation tool, bone and theinterface.

The qualimetric system includes various visual tracking mechanisms(e.g., computer navigation, MAKO assistant, fluoroscopy, and the like)in which an uncontrolled force is applied manually such as by a mallet1005. The quantitative system operates an insertion agency 1010 whichenables application of controlled forces (e.g., force vectors ofcontrolled direction and/or controlled magnitude). The insertion agencymay involve ISM which, in some implementations, may assess the stressresponse of bone at the implant/bone interface as opposed to qualimetricdiscussed in the above paragraph that does visual tracking.

The qualimetric system includes a striking-evaluation system 1015 inwhich a mallet strikes a rod which drives a prosthesis into a preparedcavity. The surgeon then qualitatively assesses the placement usingsecondary cues (audio, tactile, visual imaging) to estimate a quality ofinsertion and assume a quality of fixation. This cycle of strike andassess continues until the surgeons stop, often wondering whetherstopping is appropriate and/or whether they have struck the rod too manytimes/too hard.

In contrast, a quantitative cycle 1020 in the quantimetric systemincludes operation of an insertion agency, measurement of forceresponse(s) to determine elastic and rigidity factors, and use thesefactors to determine whether to continue operation and whether to modifythe applied force from the insertion agency. The quantitative systemassumes BFSF and optimal press-fit fixation relies primarily on a cavityaperture of a relatively oversized prosthesis/relatively undersizedcavity which provides a contact area around a “rim” of the cavity wherebone contacts, engages, and fixates the prosthesis. A depth of theaperture region may depend upon a degree of lateral compression of theprepared bone as the prosthesis is installed.

The parametric values of the quantimetric system provide meaningfulactionable information to surgeons as to when to increment the magnitudeof force, and as to when to stop application of force. Additionally,surgeons currently utilize qualitative means (auditory and tactilesenses) as well as auxiliary optical tracking means (fluoroscopy,navigation) to assess the depth of insertion and estimate a quality offixation during press fit arthroplasty. Application of force to achievepress fit fixation is uncontrolled and based on human proprioceptive andauxiliary optical tracking means. The optimal endpoint for press fitfixation remains undefined and elusive.

An embodiment may include development of a reliable quantitativetechnique for real-time intra-operative determination of optimal pressfit, and the development of a smart tool to obtain this pointautomatically. The ability to base controlled application of force forinstallation of prosthesis in joint replacement surgery on the forceresponse of the implant/bone interface is an innovative concept allowinga quantimetric evaluation of the implant/bone interface.

An embodiment for a quantimetric system may include a hand-held tool(See, e.g., FIG. 1) that can produce impact energies of the necessarymagnitude and accuracy. A variety of actuation methods can be used tocreate controlled impacts, including pneumatic actuators, electromagnetics actuators, or spring-loaded masses. An example implementationusing pneumatic, vibratory, motorized, controlled, or other actuationThe device shall have industry standard interfaces in order to allow foruse with a variety of cup models.

A slide hammer pneumatic prototype is created to allow precise andincremental delivery of energy E. It is equipped with inline forcesensors in order to measure resulting forces F1 and F2 and controlled byintegrated electronics that provides analysis of F1, F2, ΔF2, number ofimpacts, and impact energy E. Programed algorithms based on the doublebinary system described herein will produce successive impacts of aknown energy, making two simultaneous binary decisions before eachimpact: (a) modify energy or not; and (b) apply energy or not. These twobinary decisions will be based on parametric values produced by thecontrol electronics, which provides an essential feedback of theimplant/bone interface, and the elastic response of bone at theaperture. The following algorithm provides a basic example of the doublebinary decision making process.

A method for assessing a seatedness and quality of press fit fixationincludes a series of operations for installing a prosthesis into arelatively undersized cavity prepared in a portion of bone, includingcommunicating, using an installation agency, a quantized applied forceto a prosthesis being press-fit into the cavity; monitoring a rigiditymetric and an elasticity metric of the prosthesis with respect to thecavity (some embodiments do this in real-time or near real-time withoutrequiring imaging or position-determination technology); furtherprocessing responsive to the rigidity and elasticity metrics, includingcontinuing to install the prosthesis at present level of applied forcewhile monitoring the metrics when the metrics indicate that installationchange is acceptable and a risk of fracture remains at an acceptablelevel, increasing the applied force and continuing applying theinstallation agency while monitoring the metrics when the metricsindicate that installation change is minimal and a risk of fractureremains at an acceptable level, or suspending operation of theinstallation agency when the metrics indicate that installation changeis minimal when a risk of fracture increases to an unacceptable level.

1. Apply energy E1 and measure F2, number of impacts (NOI), ΔF2.

2. Monitor F2 over number of impacts (NOI), and/or monitor ΔF2 as itapproaches zero.

3. When ΔF2 approaches zero, insertion is not occurring for thatparticular energy E1. If NOI required to achieve this point issufficiently large (low speed of insertion) as determined by the controlalgorithm, then E1 is increased to E2

4. Continue steps 1 through 3 until the NOI required for ΔF2 to approachzero is sufficiently small (high speed of insertion) as determined bythe control algorithm.

5. The smart tool may be implemented so it will not generate automatedimpacts after this level is reached. Additional increase in energy E isnot recommended but can be produced manually or after a consideredoverride by the surgeon. For example, it may be that no more than oneincremental manual increase is recommended or established as a bestpractice.

Validation of the tool may be performed by comparing the quality ofinsertion (extractive force F4) produced by AI-PID with those producedby a mallet and standard impaction techniques. Specifically, the twodistinct endpoints of (i) BFSF (achieved through AI-PID) and (ii) fullseating (achieved through mallet strikes) will be compared to determinedifferences in the extractive force F4 and fracture incidence. A riskbenefit analysis will be done to determine whether additional impactsand insertion beyond BFSF provided any significant value as to implantstability, or conversely led to increased incidence of fracture of thecavity. (As noted herein, it may be the case that BFSF may be achievedwithout full seating, a stated goal of many conventional procedures.)

It is anticipated that the measurements of F2, and ΔF2 and itscomparative analysis with respect to number of impacts NOI will providea principled and organized process for application of energy to achievea desired endpoint of fixation BFSF. We expect that the first orderrelationship of ΔF2 will provide the information as to whether, for anyparticular level of applied energy, insertion is occurring or not;providing a guidance as to whether applied energy should be increased.We expect the rate of ΔF2 decay to zero will provide information aboutelastic/plastic behavior of the aperture, indicating when the maximumstrain X, normal force FN, and extractive force F4 at the aperture ofthe bone cavity have been achieved. We anticipate reproducing theresults of phase I aim 1, namely that there is a strong correlationbetween pull force F4 and rate of decay of ΔF2, that an inflection pointexists in the elasticity factor, beyond which addition of impact energywill lead to marginal gains in extraction force F4 and depth ofinsertion, mitigating against goal of full seating as the best policy.

We have indicated that the grasp of bone (bone substitute) on an implantat the aperture can be modeled in some cases by formula such as FN*Uswhere FN represents the normal forces at the interface, and Usrepresents the coefficient of static friction. FN is estimated byHooke's Law and is represented by K.X, where K represents the materialproperties of bone including the elastic and compressive moduli and Xrepresents the difference in diameter between the implant and thecavity. We note that the value of K can vary dramatically betweendifferent ages and sexes. We anticipate this tool to be capable ofautomatically producing the proper amount of impact energy E, cupinsertion CI, stretch on bone X, normal force FN, and extractive forceF4 to achieve optimal press fit for patients of various ages and sexes,eliminating an over reliance on surgeon senses and experience.

Having access to this interface sensing phenomena, an embodiment maydevelop a simple controlled impaction process that allows the surgeon toquantize the impact energy, and deliver it in a controlled andmodulatable fashion based on the above two parametric value representingthe stress/strain behavior of bone. Some embodiments may develop theconcept of controlled force application based on an evaluation of theinterface force phenomena (forces felt at the prosthesis/cavityinterface). This is in stark contradistinction of uncontrolledapplication of force with a mallet based on a VISUAL assessment/trackingof the depth of prosthesis insertion (MAKO, all navigation techniques,Fluoroscopy, Nikou—a navigation technique).

There may be many different ways to assess rigidity factor and to assessan elasticity factor. FIG. 11-FIG. 14 illustrates F2 approaching F1 andF5 approaching F1, as well as (ΔF2 approaching 0) and (ΔF5 approaching0). Additional non-illustrated ways include F3 approaching F1 and ΔF3approaching 0). As noted herein, data fusion may produce a fusionvariable that can measure, evaluate, or indicate rigidity and/orelasticity. For example, one or more of F2, F3, and F5, appropriatelyweighted, may be fused into a variable that may be used such as bycomparing to F1 or delta fused variable compared to a threshold value(such as zero).

FIG. 11-FIG. 14 illustrate a set of rigidity metric measurements thatmay be used in the methods and systems described herein. FIG. 11illustrates a comparison of F5 to F1; FIG. 12 illustrates a comparisonof ΔF5 to a predetermined threshold (e.g., 0.0); FIG. 13 illustrates acomparison of F2 to F1; and FIG. 14 illustrates a comparison of ΔF2 to apredetermined threshold (e.g., 0.0).

FIG. 15 illustrates a possible evolution of an acetabular cup 1505consistent with improving press fit fixation. As noted, a conventionalacetabular cup for an implant includes a hemispherical outer surfacedesigned to be installed/impacted into a prepared bone cavity (alsohemispherical produced from a generally hemispherical reamer forexample).

Different stages of evolution illustrate possible improvements toprosthesis embodiments that are responsive to assumptions andembodiments of the present invention. An assumption of some conventionalsystems is that full depth of insertion results in a maximum extractivepress fit fixation. In contradiction to this assumption, it may be thecase that embodiments of the present invention achieve maximum/optimalpress fit fixation (BFSF) short of full insertion (i.e., intentionalpresence of a polar gap).

There may be advantages to reducing polar gaps, and rather than fullinsertion, a modification to the prosthesis may include a truncatedhemisphere (snub nosed) cup 1510. There is a desire to reduce insertionforces while maximizing press fit fixation. Evolution of the prosthesismay incorporate several different ideas, including asymmetricdeformation control using a truncated cup with longitudinally extendingribs 1515 and laterally extending planks 1520—the combination of ribsand planks cup 1525 may produce an asymmetric deformation to improveinstallation (such as making it easier to install and more difficult toremove). Further, a perimeter of an improved cup may include a discretepolygon having many sides. The reduced surface area contacting theprepared cavity may reduce force needed to install while the vertices ofthe polygon may provide sufficient press-fit fixation. Cup 1525 mayinclude tuned values of the snub, different stiffnesses of ribs andplanks, a perimeter configuration of the regular/irregularnon-hemispherical polygonal outer surface. These vertices themselves maybe angular and/or rounded, based upon design goals of a particularimplementation of an embodiment to achieve the desired trade-offs ofinstallation efficiency and press-fit fixation to improve thepossibility of achieving BFSF.

These concepts have implications on how the acetabular (all press fitprosthesis) prosthesis are made. If it holds true that the dome of thecup mostly acts like a wedge to cause fracture, it may be best toeliminate the dome (flatten the cup) and change the geometry of the cupto be more like a frustum polygon with nth number of sides, or ahemisphere with a blunted dome.

A. With the ability to provide a proportional amount of force for anyparticular (implant/bone) interface, we can expect to use just the rightamount of force for installation of the prosthesis (not too much and nottoo little). Additionally we have previously in U.S. patent applicationSer. No. 15/234,927, expressly incorporated herein, discussed methods tomanufacture prosthesis with an inherent tendency for insertion,MECHANICAL ASSEMBELY INCLUDING EXTERIOR SURFACE PREPAREATION.Specifically, we have descried the concept of two dimensional stiffnessincorporated within the body of the prosthesis, which would produce abias for insertion due to the concept of undulatory motion, typicallyobserved in Eel and fish skin.

FIG. 15 includes a side view of a prosthesis including a two-dimensionalasymmetrical stiffness configuration, and illustrates a top view ofprosthesis. The prosthesis may include a set of ribs and one or moreplanks disposed as part of a prosthetic body, represented as analternative acetabular cup. The body may be implemented in conventionalfashion or may include an arrangement consistent with prosthesis P. Theribs and plank(s) are configured to provide an asymmetrictwo-dimensional (2D) stiffness to body that may be more conducive totransmission of force and energy through the longitudinal axis of thecup as opposed to circumferentially. Ribs are longitudinally extendinginserts within body (and/or applied to one or more exterior surfaces ofbody). Plank(s) is/are laterally extending circumferential band(s)within body (and/or applied to one or more exterior surfaces of body).For example, planks may be “stiffer” than ribs (or vice-versa) toproduce a desired asymmetric functional assembly that may provide for anundulatory body motion as it is installed into position.

Based on our understanding of the acetabular prosthesis/bone interfacein our Invasive sensing studies in one or more incorporated patentapplications and in conjunction with the incorporated '927 applicationof MECHANICAL ASSEMBELY INCLUDING EXTERIOR SURFACE PREPAREATION, weanticipate that the prosthesis of the future may have differentcharacteristics.

A. The acetabular component may be shaped more like a frustum with Nth(e.g., 160 sides) and an amputated dome. The snubbed dome of the newprosthesis would not engage the acetabular fossa (Cotyloid fossa)allowing the new prosthesis fully engage the stronger acetabularwalls/rim (constituted by the ilum, ischium and pubic bones). This shapeof prosthesis avoids the possibility of a wedge type fracture which canbe produced by the dome of a hemispherical implant.

B. Each angle of the frustum may produce longitudinal internal ribextending from the rim distally, (developed within the structure of theprosthesis by additive manufacturing by controlling the materialproperties of crystalline metal), that is more flexible than thehorizontal stiffer planks that extend from the rim to the snub distallyin a circumferential fashion. (See the incorporated '927 application).This shape of prosthesis will have a strong bias for insertion due toundulatory motion, and will require less force for installation.

Permanent or Removable Sensors on the surface of the Prosthesis.

A. As described herein, in some experiments that when F2 approaches F1,that in fact F1=F2=F3=F5. That is, when the implant/bone collisionbecomes elastic, the resistive force at the interface F3 and the forcesfelt in bone F5 can be inferred from applied force F1 and force felt intool F2. This can provide the surgeon valuable information about theforces she is imparting to the bone. We also contemplate that F3 and F5can be directly measured by application of mechanical and biologicsensors directly on a sensing prosthesis 1530. We believe given the massproduction and ubiquitously available sensors, at some point, theprosthesis of the future would be equipped with its own sensor (biologicand or mechanical) to convey to the surgeon the forces being impartedinto the bone, to prevent excessive forces on bone, as well as toprevent loose fitting prosthesis. Sensors on the applied on the surfaceof the prosthesis to measure interface or dome pressure (F3 or F5) canbe permanent or removable i.e., a slot on the side of the prosthesis canallow incorporation of a small sliding sensor to provide informationabout the interface to the system. Examples of incorporated sensors, oneor more which may be used, may include an internal sensor 1535, amechanical sensor 1540, a biologic sensor 1545, and an external sensor1550.

B. Data Fusion of F2, F5, F3 for most sensitive evaluation of stressresponse of Bone at the Implant Bone Interface—multiple parameters areweighted and merged or fused that may provide a robust parameteroffering improved performance over reliance on a single parameter.

2. Application of Force based on a Sensory (Not Visual) Evaluation ofImplant/Bone Interface.

A. For years surgeons have applied uncontrolled force to impactprosthesis into bone, and have assessed the quality of insertion byhuman visual, tactile and auditory means. More recently surgeons havebegun to use visual tracking means such as fluoroscopy, computernavigation (including Nikou), and MAKO techniques to assess depth ofinsertion. We are the first to suggest that the application of force forinstallation of prosthesis should be predicated on the force sensingactivity of the prosthesis/bone interface. This is a new technique thatpredicates application of force for installation of prosthesis to bebased (NOT VISUAL TRACKING MEANS—depth of insertion) but rather (FORCESENSING MEANS OF THE INTERFACE—proof resilience). This is a novelconcept that will eliminate too tight and too loose press fit fixationof all prosthesis, and associated problems such as subsidence,loosening, and infection.

FIG. 16 illustrates a particular embodiment of a BMD_(X) force sensingtool 1600. Tool 1600 allows indirect measurement of a rate of insertionof an acetabular cup and may be used to control the impact force beingdelivered to a prosthesis based upon control signals and the use offeatures described herein. Tool 1600 may include a controllable forceapplicator (e.g., an actuator) 1605, an impaction transfer structure1610 (e.g., impaction rod), and a force sensor 1615.

Applicator 1605 may include a force sensor to measure/determine F1 (insome cases applicator 1605 may be designed/implemented to apply apredetermined and known a priori force.

Structure 1610 transfers force as an insertion agency (for prosthesisimplant applications) to prosthesis P and sensing system 1615 measures arealtime (or near realtime) force response of prosthesis P to theinsertion agency while it is being implanted into the implant site.There are many different possible force response mechanisms as describedherein. For example, F2, F3, F5, and first/second order derivatives andcombinations thereof as noted herein. In some cases, sensing system 1615may include in-line or external sensor(s) associated with or coupled tostructure 1610. In other cases, some embodiments of system 1615 mayinclude sensor(s) associated with the bone or cavity or other aspect ofthe cavity, prosthesis, cavity/prosthesis interface or other forceresponse parameter. System 1615, as noted herein, may include multipleconcurrent sensors from different area including one or more of tool,prosthesis and bone/cavity.

One representative method for force measurement/response would employsuch a tool 1600. Similar to the impaction rod currently used bysurgeons, tool 1600 may couple to an acetabular cup (prosthesis P) usingan appropriate thread at the distal end of structure 1610. Applicator1605 may couple to a proximal end of structure 1610, and create aninsertion agency (e.g., controlled and reproducible impacts) that wouldbe applied to structure 1610 and connected cup P. A magnitude of theimpact(s) would be controlled by the surgeon through a system control1620, for example using an interface such as a dial or other inputmechanism on the device, or directly by the instrument's software.System control 1620 may include a microcontroller 1625 in two-waycommunication with a user interface 1630 and receiving inputs from asignal conditioner 1635 receiving data from force sensing system 1615.Controller 1625 is coupled to actuator 1605 to set a desired impactprofile including a set of force applications that may change over timeas described herein.

Sensing system 1615 may be mounted between structure 1610 and acetabularcup P. System 1615 may be of a high enough sampling rate to capture thepeak force generated during an actuator impact. It is known that formultiple impacts of a given energy, the resulting forces increase as theincremental cup insertion distance decreases/

This change in force given the same impact energy may be a result of thefrictional forces between cup P and surrounding bone of the installationsite. An initial impact may have a slow deceleration of the cup due toits relatively large displacement, resulting in a low force measurement.The displacement may decrease for subsequent impacts due to theincreasing frictional forces between the cup and bone, which results infaster deceleration of the cup (the cup is decelerating from the sameinitial velocity over a shorter distance). This may result in anincrease in force measurement for each impact. A maximum force for agiven impact energy may be when the cup P can no longer overcome,responsive to a given impact force from the actuating system, theresistive (e.g., static friction) forces from the surrounding bone. Thisresults in a “plateau”, where any subsequent impact will not changeeither the insertion of cup P or the force measured.

In some embodiments, this relationship may be used to “walk up” theinsertion force plot, allowing tool 1600 to find the “plateau” of largerand larger impact energies. By increasing the energy, the relationshipbetween measured impact force and cup insertion should hold until thesystem reaches a non-linear insertion force regime. When the non-linearregime is reached, a small linear increase in impact energy will notovercome the higher static forces needed to continue to insert the cup.This will result in an almost immediate steady state for the measuredimpact force (mIF of a force application X is about the same as MIF of aforce application X+1).

A procedure for automated impact control/force measurement may include:a) Begin operation of an insertion agency with a static, low energy; b)Record the measured force response (MIF); c) continue operation of theinsertion agency until the difference in measured impact forceapproaches zero (dMIF=>0), inferring that the cup is no longerdisplacing; d) increase the energy of the operation of the insertionagency by a known, relatively small amount; and e) repeat operation ofthe modified insertion agency until plateau and increasing energy in afashion (e.g., a linear manner) until a particular plateau patterning isdetected. Instead, an increase in energy results in a “step function” inrecorded forces, with an immediate steady-state. The user could benotified of each increase in energy, allowing a decision by the surgeonto increase the resulting impact force.

A goal of a validated ISM concept is to produce a sophisticated tool fora surgeon that provides automatic, intelligent prosthesis installation,with the capacity to provide access to an optimal best fixation short offracture (BFSF) endpoint inherent in any implant/cavity system. Thistool will allow surgeons of all walks of life, regardless of level ofexperience, to obtain the best possible press fit fixation of anycup/cavity system, without fear of too loose or tight press fit, as wellas obviating the need for screw fixation with all its attendantproblems.

The tool may include a handheld pneumatic instrument with a sliding masscomponent. It may have the following features: 1) ability to deliverprecisely controlled axial impacts of known impact energy E, 2) abilityto increase or modify applied force (F1) over the course of use, 3)ability to acquire the resulting F1, F2, F3, and F5 for each impact, 4)ability to automatically control the application of impact energy tooptimally seat an acetabular cup (implant) using the algorithmsdetermined in Phase I, 5) communicate data pertaining to ISM and BFSF tothe surgeon, 6) allow for manual override and selection of impact energyby the surgeon.

Actuators of applicator 1605 may include a one or more of a wide varietyof devices (or combinations thereof), including pneumatic actuators,electro-magnetic actuators, spring-loaded masses, and the like.

The device may have industry standard interfaces in order to allow foruse with a variety of cup models. For the example implementation, theimpact energy is controlled through a piston actuation control mechanismand by additional adjustments of sliding mass and travel distance. Oncea final actuation method is selected, a working prototype will bedesigned and fabricated to allow for controlled insertion of acetabulumcups.

The instrument may be equipped with inline force sensors and wirelessconnectivity in order to determine resulting forces F1, F2, F3, F5within the system. Applied force F1 and felt force within the tool (F2)will be measured using internal sensors, whereas the forces felt in bone(F5) and at the implant/bone interface (F3) will be measured separatelywith appropriately placed sensors in the system and the data conveyed tothe central processing unit (CPU) through wireless (intranet) systems.

The tool will be controlled by integrated electronics that provideanalysis of the inter-relationships between F1, F2, F3, F5 with respectto number of impacts (NOI) to full insertion, and impact energy. Themagnitude of the impacts will be controlled by a CPU (FIG. 16) andassociated software, where the system control may include amicrocontroller in two-way communication with a user interface andreceive inputs from a signal conditioner, which receives data (directlyor indirectly) from the sensors within the system. The microcontrollerwill be coupled to the actuator to set a desired impact energy and run afixation algorithm to obtain endpoint BFSF.

Programmed algorithms based on the binary decision system described inPhase I Specific Aim #1 will produce successive impacts of known energy,making two simultaneous decisions before each impact: 1. Continueapplying force or not, and if so, then 2. Increase energy or not. Thesebinary decisions will be based on parametric values produced by thecontrol electronics, which provide essential feedback of theimplant/bone interface, and the elastic response of bone at theaperture. The following algorithm provides a basic example of the binary“fixation algorithm” to be incorporated in the control mechanism: (i)apply energy E1 and measure F2, NOI, ΔF2; (ii) monitor F2 over NOI,and/or monitor ΔF2 as it approaches 0; (iii) when ΔF2 approaches 0,insertion is not occurring for that particular energy E1. If NOIrequired to achieve this point is sufficiently large (low rate ofinsertion), as determined by the control algorithm, then E1 is increasedto E2; (iv) continue steps (i) through (iii) until the NOI required forΔF2 to approach 0 is sufficiently small (high rate of insertion), asdetermined by the control algorithm; (v) the sophisticated tool will notgenerate automated impacts after this level is reached. Additionalincrease in energy E is not recommended but can be produced manually atthe surgeon's discretion. No more than one incremental manual increaseis recommended.

As noted earlier, our preliminary data indicate that force measurementsdirectly at the interface (F3), and in bone (F5) will show similartrends and characteristics as F2, such that although independent, theymay be considered redundant, complimentary and/or cooperative. We expectto be able to incorporate these data into an independent systemarchitecture and utilize existing data fusion algorithms to potentiallyproduce a higher resolution evaluation of the stress (force) fieldaround the implant/bone interface than with each individual sensoralone.

Validation of the tool will be performed at Excelen and at theUniversity of Minnesota Department of Engineering by comparing thequality of insertion (extractive force F4) produced by AI-PID—whichautomatically achieves endpoint BFSF—with the quality produced by amallet and standard impaction techniques accomplished by a boardcertified orthopedic surgeon blinded to the study. Specifically, the twodistinct endpoints of 1. BFSF (achieved through AI-PID) and 2. FullSeating (achieved through mallet strikes) will be compared to determinedifferences in F4 and fracture incidence. All parameters associated withthese two endpoints will be compared and evaluated. Specifically, a riskbenefit analysis will be performed to determine whether higher impactenergies were required to obtain full seating, and if so, whether theadditional impacts provided any significant value as to CI or F4, andwhether there was any increase in fracture incidence (failure of thecavity) with either technique.

Interpretation of Results:

Measurements of F2 and ΔF2 and their first and second order derivativesand comparative analysis with respect to NOI to insertion may provide aprincipled and organized process for application of energy to achievethe desired optimal endpoint BFSF. It is anticipated that the secondorder relationship of ΔF2 to NOI, alternatively stated as the rate ofdecay of ΔF2 (how fast ΔF2 approaches 0) may provide an evaluation ofelastic/plastic deformation and also contribute to achieving BFSF.

The following references, expressly incorporated by reference hereto intheir entireties for all purposes, support one or more of the conceptsor ideas presented herein, including: 1) Udomkiat P, Dorr L D, Wan Z.Cementless hemispheric porous-coated sockets implanted with press-fittechnique without screws: average ten-year follow-up. J Bone Joint Surg.2002; 84A:1195. 2) Takedani H, Whiteside L A, White S E, et al. Theeffect of screws and pegs on cementless acetabular fixation. TransOrthop Res Soc 1991; 16:523; 3) lAhnfelt, L., P. Herberts, H. Malchau,and G. Andersson. Prognosis of total hip replacement: a swedishmulticenter study of 4664 revisions. Acta Orthop. Scand. 61:2-26, 1990;4) Corbett, K. L., E. Losina, A. A. Nti, J. J. Prokopetz, and J. N.Katz. Population-based rates of revision of primary total hiparthroplasty: a systematic review. PLoS ONE 5:e13520, 2010; 5) Huiskes,R. Failed innovation in total hip replacement: diagnosis and proposalsfor a cure. Acta Orthop. Scand. 64:699-716, 1993; 6) Harris, W. Asepticloosening in total hip arthroplasty secondary to osteolysis induced bywear debris from titanium-alloy modular femoral heads. JBJS. 73:470-472,1991; 7) Kobayashi, S., K. Takaoka, N. Saito, and K. Hisa. Factorsaffecting aseptic failure of fixation after primary charnley total hiparthroplasty multivariate survival analysis. JBJS. 79:1618-1627, 1997;8) Lombardi Jr, A. V., T. Mallory, B. Vaughn, and P. Drouillard. Asepticloosening in total hip arthroplasty secondary to osteolysis induced bywear debris from titanium-alloy modular femoral heads. JBJS.71:1337-1342, 1989; 9) Huiskes, R. Failed innovation in total hipreplacement: diagnosis and proposals for a cure. Acta Orthop. Scand.64:699-716, 1993; 10) Clohisy, J. C., G. Calvert, F. Tull, D. McDonald,and W. J. Maloney. Reasons for revision hip surgery: a retrospectivereview. Clin. Orthop. Relat. Res. 429:188-192, 2004; 11) Kim, Y. S., J.J. Callaghan, P. B. Ahn, and T. D. Brown. Fracture of the acetabulumduring insertion of an oversized hemispherical component. JBJS.77:111-117, 1995; 12) Sharkey, P. F., W. J. Hozack, J. J. Callaghan, Y.S. Kim, D. J. Berry, A. D. Hanssen, and D. G. LeWallen. Acetabularfracture associated with cementless acetabular component insertion: areport of 13 cases. J. Arthro-plast.14:426-431, 1999; 13) Weeden, S. H.and W. G. Paprosky. Minimal 11-year follow-up of extensivelyporous-coated stems in femoral revision total hip arthroplasty. J.Arthroplast. 17:134-137, 2002; 14) Ulrich A D, Seyler T_(M), Bennett D,Celanois R E, Saleh K J, Thongtrangan I, Kuskowski M, Cheng E Y, SharkeyP F, Parvizi J, Stiehl J B, Mont M A. Total hip arthroplasties: What arethe reasons for revision? International Orthopedics (SICOT) (2008) 32:597-604; 15) Olory, B., E. Havet, A. Gabrion, J. Vernois, and P. Mertl.Comparative in vitro assessment of the primary stability of cementlesspress-fit acetabular cups. Acta Orthop. Belg. 70:31-37, 2004; 16)Meneghini, R. M., C. Meyer, C. A. Buckley, A. D. Hanssen, and D. G.Lewallen. Mechanical stability of novel highly porous metal acetabularcomponents in revision total hip arthroplasty. J. Arthroplast.25:337-341, 2010; 17) Fehring, K. A., J. R. Owen, A. A. Kurdin, J. S.Wayne, and W. A. Jiranek. Initial stability of press-fit acetabularcomponents under rotational forces. J. Arthroplast 29:1038-1042, 2014;18) Georgiou, A., and J. Cunningham. Accurate diagnosis of hipprosthesis loosening using a vibrational technique. Clin. Biomech.16:315-323, 2001; 19) Balch C M, Freischlag J A, Shanafelt T, Stress andBurnout Among Surgeons. ARCH SURG/VOL 144 (NO. 4) April 2009; 20)Shanafelt T D, Balch C M, Bechamps G J, Tussell T, Dyrbye L, Satele D,Collicott P, Novotny P J, Sloan J, Freischlang J A Burnout and CareerSatisfaction Among American Surgeons Ann Surg 2009; 250: 107-115; 21)Ulrich A D, Seyler T_(M), Bennett D, Celanois R E, Saleh K J,Thongtrangan I, Kuskowski M, Cheng E Y, Sharkey P F, Parvizi J, Stiehl JB, Mont M A. Total hip arthroplasties: What are the reasons forrevision? International Orthopedics (SICOT) (2008) 32: 597-604; 22)Kurtz S, Ong K, Lau E, Mowat F, Halpern M, Projections of Primary andRevision Hip and Knee Arthroplasty in the United States from 2005 to2030 JBJS (2007) Am 89: 780-785; 23) Nakasone S, Takao M, Nishii T,Sugano N, Incidence and Natural Course of Initial Polar Gaps inBirmingham Hip Resurfacing Cups. J of Arthroplasty Vol 27, (9)1676-1682; and 24) Springer B D, Griffin W L, Fehring T K, Suarez J,Odum S, Thompson C Incomplete Seating of Press-Fit porous CoatedAcetabular Components (2008) J of Arthroplasty Vol 23 (6) 121-126.

The system and methods above has been described in general terms as anaid to understanding details of preferred embodiments of the presentinvention. In the description herein, numerous specific details areprovided, such as examples of components and/or methods, to provide athorough understanding of embodiments of the present invention. Somefeatures and benefits of the present invention are realized in suchmodes and are not required in every case. One skilled in the relevantart will recognize, however, that an embodiment of the invention can bepracticed without one or more of the specific details, or with otherapparatus, systems, assemblies, methods, components, materials, parts,and/or the like. In other instances, well-known structures, materials,or operations are not specifically shown or described in detail to avoidobscuring aspects of embodiments of the present invention.

Reference throughout this specification to “one embodiment”, “anembodiment”, or “a specific embodiment” means that a particular feature,structure, or characteristic described in connection with the embodimentis included in at least one embodiment of the present invention and notnecessarily in all embodiments. Thus, respective appearances of thephrases “in one embodiment”, “in an embodiment”, or “in a specificembodiment” in various places throughout this specification are notnecessarily referring to the same embodiment. Furthermore, theparticular features, structures, or characteristics of any specificembodiment of the present invention may be combined in any suitablemanner with one or more other embodiments. It is to be understood thatother variations and modifications of the embodiments of the presentinvention described and illustrated herein are possible in light of theteachings herein and are to be considered as part of the spirit andscope of the present invention.

It will also be appreciated that one or more of the elements depicted inthe drawings/figures can also be implemented in a more separated orintegrated manner, or even removed or rendered as inoperable in certaincases, as is useful in accordance with a particular application.

Additionally, any signal arrows in the drawings/Figures should beconsidered only as exemplary, and not limiting, unless otherwisespecifically noted. Combinations of components or steps will also beconsidered as being noted, where terminology is foreseen as renderingthe ability to separate or combine is unclear.

The foregoing description of illustrated embodiments of the presentinvention, including what is described in the Abstract, is not intendedto be exhaustive or to limit the invention to the precise formsdisclosed herein. While specific embodiments of, and examples for, theinvention are described herein for illustrative purposes only, variousequivalent modifications are possible within the spirit and scope of thepresent invention, as those skilled in the relevant art will recognizeand appreciate. As indicated, these modifications may be made to thepresent invention in light of the foregoing description of illustratedembodiments of the present invention and are to be included within thespirit and scope of the present invention.

Thus, while the present invention has been described herein withreference to particular embodiments thereof, a latitude of modification,various changes and substitutions are intended in the foregoingdisclosures, and it will be appreciated that in some instances somefeatures of embodiments of the invention will be employed without acorresponding use of other features without departing from the scope andspirit of the invention as set forth. Therefore, many modifications maybe made to adapt a particular situation or material to the essentialscope and spirit of the present invention. It is intended that theinvention not be limited to the particular terms used in followingclaims and/or to the particular embodiment disclosed as the best modecontemplated for carrying out this invention, but that the inventionwill include any and all embodiments and equivalents falling within thescope of the appended claims. Thus, the scope of the invention is to bedetermined solely by the appended claims.

1-15. (canceled)
 16. A method for an insertion of an implant into acavity in a portion of bone, the cavity configured for a pressfitfixation with respect to the implant, comprising: a) providing, using adevice, an implant insertion force to the implant to transition theimplant toward a deepen insertion into the cavity; and b) predicting, inreal-time and responsive to said implant insertion force, a press-fitfixation of the implant at an interface between the implant and thecavity during said providing of said implant insertion force.
 17. Themethod of claim 16 wherein said implant insertion force of step a)includes applying an applied force to said device; wherein said deviceincludes an implant insertion implement, coupled to the implant andoperative at said interface; and wherein said step b) includesmeasuring, responsive to an application of said applied force to saiddevice, a measured force within said device wherein said measured forceis responsive to operation of the implant on the portion of bone at saidinterface responsive to said applied force.
 18. The method of claim 17wherein said step b) further includes comparing a magnitude of saidapplied force to a magnitude of said measured force.
 19. An impactcontrol method for installing an implant into a cavity in a portion ofbone, the cavity configured for a pressfit fixation with respect to theimplant, comprising: a) imparting a first initial known force to theimplant; b) imparting a first subsequent known force to the implant,said first subsequent known force about equal to said first initialforce; c) measuring, for each said imparted known force, an X^(th)number measured impact force; d) comparing said X^(th) measured impactforce to said X^(th)−1 measured impact force against a predeterminedthreshold for a threshold test; and e) repeating steps b)-d) as long assaid threshold test is negative.
 20. The method of claim 19 furthercomprising: f) providing an indication when said threshold test ispositive.
 21. The method of claim 19 further comprising: f) imparting asecond initial known force to the implant, said second initial knownforce greater than said first initial known force; g) imparting a secondsubsequent known force to the implant, said second subsequent knownforce about equal to said second initial force; h) measuring, for eachsaid applied force, an Y^(th) number measured impact force; i) comparingsaid Y^(th) measured impact force to said Y^(th)−1 measured impact forceagainst said predetermined threshold for a second threshold test; and j)repeating steps g)-i) as long as said second threshold test is negative.22. The method of claim 19 further comprising: f) providing anindication when said threshold test is positive and X is less than orequal to three.
 23. A method for an automated installation of an implantinto a cavity in a portion of bone, comprising: a) initiating anapplication of an installation force to the implant, said installationforce including an energy communicated to the implant moving the implantdeeper into the cavity in response thereto; b) recording a set ofmeasured response forces responsive to said installation force; c)continuing applying and recording until a difference in successivemeasured responses is within a predetermined threshold to estimate nosignificant displacement of the implant at said energy as the implant isinstalled into the cavity; d) increasing said energy; e) repeating stepsb)-c) until a plateau of said set of said measured response forces; andf) terminating steps b)-e) when a steady-state is detected.
 24. A methodfor insertion of a prosthesis into a cavity formed in a portion of bone,the prosthesis configured for a pressfit fixation with respect to thecavity, comprising: a) applying an insertion force to the prosthesis,said insertion force operating over a period, said period including aninitial prosthesis insertion act with said insertion device and asubsequent prosthesis insertion act with said insertion device; and b)providing a real-time parametric evaluation, during said period, of anextractive force of an interface between the prosthesis and the cavityduring said period, said parametric evaluation including an evaluationof a set of factors of the prosthesis with respect to the cavity, saidset of factors including one or more of a rigidity factor, an elasticityfactor, and a combination of said rigidity factor and said elasticityfactor.
 25. The method of claim 24 wherein one or more said factors ofsaid set of factors each include a plurality of fused weightedparameters.
 26. The method of claim of 25 wherein one of said pluralityof fused weighted factors include one or more of a first weighted F2, asecond weighted F3, and a third weighted F5.
 27.

force

force

force


28. A method for installing a prosthesis into a cavity prepared in aportion of bone, the cavity configured for a pressfit fixation,comprising: a) communicating an application force F1 to the prosthesis;b) monitoring a rigidity factor and an elasticity factor of theprosthesis within the cavity during application of the application forceF1; c) repeating a)-b) until said rigidity factor meets a firstpredetermined goal; d) increasing, when said rigidity factor meets saidpredetermined goal, said application force F1; e) repeating a)-d) untilsaid elasticity factor meets a second predetermined goal; and f)suspending a) when said elasticity factor meets said first goal and saidrigidity factor meets said second goal.
 29. The method of claim 28wherein said elasticity factor includes a tool-interface response forceF2 and wherein said first predetermined goal includes a ΔF2 within afirst predetermined threshold.
 30. The method of claim 28 wherein saidelasticity factor includes a prosthesis-interface response force F3 andwherein said first predetermined goal includes a ΔF3 within a firstpredetermined threshold.
 31. The method of claim 28 wherein saidelasticity factor includes a bone-interface response force F5 andwherein said first predetermined goal includes a ΔF5 within a firstpredetermined threshold.
 32. The method of claim 29 wherein saidrigidity factor includes a number of impacts (NOI) and wherein saidnumber of impacts exceeds a second predetermined threshold.
 33. Themethod of claim 30 wherein said rigidity factor includes a number ofimpacts (NOI) and wherein said number of impacts exceeds a secondpredetermined threshold.
 34. The method of claim 31 wherein saidrigidity factor includes a number of impacts (NOI) and wherein saidnumber of impacts exceeds a second predetermined threshold.
 35. Themethod of claim 28 further comprising: g) overriding manually, after f),said suspension of said application force F1 to increase saidapplication force F1 to an increased application force and operate saidinsertion force to apply said increased application force to theprosthesis within the cavity. 36-47. (canceled)